Dagyaran et al.

BMC Health Services Research (2021) 21:666

https://doi.org/10.1186/s12913-021-06637-4

RESEARCH Open Access

Like soldiers on the front – a qualitative

study understanding the frontline
healthcare professionals’ experience of
treating and caring for patients with
COVID-19
Ilkay Dagyaran1 , Signe Stelling Risom2,3,4 , Selina Kikkenborg Berg2,4,5 , Ida Elisabeth Højskov6 ,
Malin Heiden1 , Camilla Bernild2 , Signe Westh Christensen2* and Malene Missel6

Abstract
Background: While people in the societies must stay home to reduce spread of the newly discovered coronavirus,
healthcare professionals do the exact opposite. For them the coronavirus is an enemy that should be defeated as a
part of one’s job. They do, however, also have a daily life with family while doing their work obligations. The
purpose of this study was to gain an in-depth understanding of the frontline healthcare professionals’ experience of
balancing work life and family life during the COVID-19 pandemic.
Methods: A sample of 22 frontline healthcare professionals caring for patients with COVID-19 was included and
interviewed individually from May to August 2020. Ricoeur’s phenomenological hermeneutical philosophy inspired
the methodology in this study.
Result: Frontline healthcare professionals treating and caring for patients with COVID-19 are, voluntarily or
involuntarily, forced to be ready to change departments as well as being ready to face the unknown coronavirus.
The frontline work leads to feelings of being abandoned among their families and friends due to the threat of
bringing the infection home and spreading the virus. Although healthcare professionals are facing a working life
filled with uncertainty and unpredictability impacting their family life, they express opposing feelings of being a
part of something bigger.
Conclusions: The work life balance for these healthcare professionals is threatened by changes in professional
responsibilities, working hours and shifts. Fear of bringing the infection home challenges them ethically and creates
a distance between healthcare professionals and their families, leading to a conflict within the individual if their
work on the frontline is worth it - or if it is a too high price to pay. Despite facing a working life filled with
uncertainty and unpredictability the healthcare professionals are being a part of something bigger that contributes
to a fighting spirit and professional pride outweighing the negative consequences; like being soldiers on the front.
Keywords: 2019-nCoV; COVID-19, Coronavirus, Qualitative study, Ricoeur, Healthcare professionals, Work life balance

* Correspondence: signe.westh.christensen@regionh.dk
2
Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen,
Denmark
Full list of author information is available at the end of the article

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Dagyaran et al. BMC Health Services Research (2021) 21:666
Introduction
Healthcare professionals (HCPs) worldwide have been
praised for their frontline efforts in the care and treat-
ment for patients with COVID-19 in the current pan-
demic situation. It has been reported how they approach
these tasks with a stoic calm and an altruistic attitude as
well as how their strong professional identity overrides
most concerns about their own health. These HCPs see
the coronavirus as an enemy that should be defeated as
a part of one’s job. They do, however, also have a daily
life with family and other interests while doing their
work obligations. In this study we investigated how these
frontline HCPs balance their work obligations and their
family life during the current COVID-19 pandemic. The
study offers an in-depth understanding of what is at
stake for HCPs caring for and treating patients with
COVID-19 infection while still maintaining a usual fam-
ily life. These findings should be of interest to a broad
worldwide readership within healthcare and will add
knowledge to the growing COVID-19 evidence base and
in developing supportive interventions targeted HCPs
during pandemics in the future.
Background
In January 2020 the World Health Organization declared
a Public Health Emergency of International Concern as
the newly discovered coronavirus, causing COVID-19
disease, was considered to have caused a global pan-
demic [1]. The COVID-19 disease mainly attacks the hu-
man respiratory system causing clinical symptoms such
as coughing and dyspnea followed by fever and bilateral
lung infiltrates shown by imaging [2, 3]. Individuals with
severe symptoms and suspected infection are monitored
and diagnosed in hospitals and are being isolated, while
those with mild symptoms are isolated at home [4].
Studies show how this global pandemic pressures health-
care systems to the extreme worldwide with a pervasive
workload for HCPs working against an unprecedented
and contagious virus [5, 6]. To contain the potentially
devasting consequences and limiting the spread of virus,
many governments have imposed very strict and drastic
measures in societies such as closure of unnecessary ac-
tivities and recommendations of staying home [7]. While
people in the societies must stay home and work from
home to reduce spread of virus, HCPs do the exact op-
posite. HCPs are currently desperately needed and the
world’s most important resource in the fight against the
pandemic, but at the same time they represent one of
the most vulnerable populations. Studies have docu-
mented how these HCPs are put under pressure both
physically and psychologically due to increased work-
load, fear and anxiety of getting infected themselves and
bringing the virus to other vulnerable patients or home
to their family members [8–11]. The protection of HCPs
Page 2 of 10
is as such vital in continuing patient care in healthcare
systems that are currently challenged by the pandemic,
but also important in ensuring not spreading the virus.
Historically, nurses have always played an important
role in prevention and control of infections and public
health [12–14]. The fight against COVID-19 is, however,
dependent on extraordinary efforts from, and collabor-
ation between, various HCPs, e.g. nurses, doctors, phys-
iotherapists, pharmacists and porters [15]. They are
currently facing frontline care and treatments for pa-
tients with COVID-19. These HCPs have to do this job
under new working conditions, both due to the physical
work environment in newly created COVID-19 depart-
ments as well as professionally depending on their previ-
ous knowledge, skills and experiences. While research
has described how HCPs during the first phase of the
COVID-19 pandemic approached their obligations with
a stoic and altruistic orientation towards their work [15],
others have reported how questions of who will step up
to the plate in this ongoing crisis arise [16]. These front-
line HCPs are additionally forced to adapt to a job that
can be unpredictable in relation to working hours and
schedule which might impact and have consequences for
their work life balance [17]. Work life balance refers to
the ability of individuals to coordinate work and family
obligations successfully which impact mental and phys-
ical health [18, 19], however, to our knowledge little at-
tention has been paid to this aspect of the caring and
treatment responsibilities for frontline HCPs during the
current COVID-19 pandemic. Therefore, the purpose of
this study was to gain an in-depth understanding of
frontline healthcare professionals’ experiences of balan-
cing work life and family life during the COVID-19
pandemic.
Methods
This study applied a qualitative explorative design using
individual interviews. Ricoeur´s phenomenological her-
meneutical philosophy created the epistemological
stance for exploring HCPs’ lived experiences of how they
balanced work life and family life during the current
COVID-19 pandemic. This approach offers a frame in
which participants’ lived experiences can be interpreted
and thus, a comprehensive understanding can be
achieved.
Sample
Participants in this study were recruited from a popula-
tion of HCPs who had a frontline caring and/or treat-
ment responsibility for patients infected with COVID-19
during the first phase of the pandemic in Denmark.
These HCPs were not normally necessarily employed to
care for or treat infectious patients specifically but be-
came part of the emergency response at the onset of the
Dagyaran et al. BMC Health Services Research (2021) 21:666 Page 3 of 10

pandemic due to either their specific competencies or Table 1 Sociodemographic characteristics of the included
on a voluntary basis. Specific competencies, in addition participants
to being a specialist in infectious diseases, could involve Descriptions Number (n)
intensive, anesthesiologic, cardiopulmonary or other Region in Denmark
relevant care and treatment experience and knowledge, Capital 14
while HCPs from other medical areas signed up at a vol-
Zealand 2
untary basis due to the urgency of the situation. We
North Jutland 2
used a convenience sampling strategy [20] by encour-
aging HCPs from different regions of Denmark to ap- Central Jutland 4
proach the research team by phone or e-mail if they Southern Denmark 0
were willing to attend an interview. The interviews were Sex
conducted by telephone based on ethical accountability Female 12
for not contributing to the spread of the virus. Twenty-
Male 10
two HCPs consented to participate in interviews from
Age
May to August 2020. Data saturation was thereafter
achieved, making further interviewing unnecessary [20]. 21–30 6
HCPs with different professional backgrounds and dif- 31–40 9
ferent responsibilities were included. The characteristics 41–50 4
of the participants are shown in Table 1. 51–70 3
Profession
Nurse 8
Data collection
According to Ricoeur, human experiences are character- Doctor 6
ized by unreflecting preunderstanding [21, 22]. In order Physiotherapist 5
to gain access to the lived experiences of caring for, and Medical Laboratory Technologist 1
treating patients with COVID-19, a narrative approach Occupational therapist 1
was used for data collection during individual interviews.
Porter 1
The participating HCPs’ expressions reflected their expe-
Years in profession
riences as they saw them and wanted to present them.
The interviews were open-ended in order to explore the 0–10 years 9
HCPs’ lived experiences and emphasised listening to 11–20 years 10
them. Narrative accounts of participant experiences were 21–44 years 3
encouraged but questions such as “Could you please tell Original Specialty / Department
me about how you experience caring for patients with
Intensive care 8
COVID-19?” and “How do you feel about being on the
Accident and emergency 2
frontline at work during such a pandemic while also be-
ing part of a family with accompanying responsibilities?” Infectious disease 1
were used during the interviews. Table 2 lists the inter- Pediatrics 1
view questions. Four experienced qualitative researchers, PhD student / Researcher 3
who were not a part of the clinical care and treatment Gastrointestinal 1
for COVID-19 infected patients, performed the inter-
Ear, nose and throat (ENT) 1
views. The researchers interviewed HCP’s that they did
Pulmonology 2
not know in advance in order to be as open and curious
as possible. The interviews lasted on average 25 min and Cardiology 1
were recorded and transcribed. Endocrinology 1

Ethical considerations
The study was approved by the Danish Data Protection
Agency (P-2020-276) and was undertaken in accordance
with the guidelines of the Danish Research Ethics Review
of Health Research Projects. The principles outlined in
the Declaration of Helsinki was followed. Written infor-
mation about the purpose of the study and the right to
withdraw at any time was handed out to the participat-
ing HCPs before deciding to participate. Written in-
formed consent was obtained from each of the
participants before the interview. Data were anonymized
by means of identification codes and the participating
HCPs were informed that interview data would be
treated confidentially.
Dagyaran et al. BMC Health Services Research (2021) 21:666 Page 4 of 10

Table 2 Interview questions
Could you please tell about:
• What thoughts you had before you embarked on the task/job?
• What it means for you to care for / treat patients with COVID-19 - both
professionally and personally?
• How you have experienced the collaboration with colleagues during
the period?
• What thoughts you have had about infection? (at work/at home/in
society)
Data analysis
Embedded in language, according to Ricoeur [21, 22], is
always a meaning that extends beyond the direct linguis-
tic expression and such linguistic connotations can only
be approached through a process of interpretation. A
Ricoeur-inspired interpretation process consists of dif-
ferent layers of meaning understood as an endless spiral
involving three levels: a naive search for the overarching
meaning which the text seeks to convey, a linguistically
oriented structural analysis, and an in-depth comprehen-
sive interpretation [22, 23]. First, reading and re-reading
of the transcribed texts took place to gain an initial un-
derstanding of what the texts were about as a naive in-
terpretation of the narratives. Secondly, a structural
analysis was performed providing an insight into the
structure of the texts. Words and sentences which
pointed towards an issue or a theme that recurred
throughout the texts were extracted. The structural ana-
lysis exceeded the naive understanding and enabled a
more in-depth interpretation. At the third level of ana-
lysis we continued with an in-depth interpretation and
discussion of the themes identified in the structural ana-
lysis. Where a structural analysis solely was aimed at a
closed system of symbols, this comprehensive interpret-
ation aimed at understanding the meaning of frontline
HCPs’ experiences of balancing work life and family life
during the COVID-19 pandemic. All authors performed
the analysis and interpretation.
Results
The understanding of frontline HCPs’ experiences of
balancing work life and family life during the COVID-19
pandemic are described in three themes: (1) Readiness
for change, (2) A sense of being abandoned among
family, and (3) Opposing feelings about being a part of
something bigger. In the following, these themes will be
illuminated in-depth one by one complemented by sub-
themes, while Table 3 is showing the key areas to en-
hance the visibility to the reader.
Readiness for change
Feelings of being pressured
The participating HCPs described how they were forced
by the acute outbreak to be ready for changes. A sense
of having a say as well as having the opportunity of
choosing to work in COVID-19 wards was crucial for
their readiness for change and motivation to work at
short notice. While some HCPs found it natural to be
part of the frontline, others felt pressured to do so and
described feelings of being deprived of the right to
choose whether they wanted to work in a specialized
COVID-19 ward or not.
I have not signed up to work in the COVID ward….
She [the boss] called and said that she had been
instructed to find three [HCPs for the COVID-19
ward], and she had half an hour to do that. She was
a little panicked and I could hear the hidden: “we
are counting on you” in her voice. She also said that
two others already had agreed to the task, so they
just needed me.
This involuntary pressure experienced by the HCPs
pushed them to be ready for changes. For some HCPs
this push meant they were growing and felt important
and ready for the changes while for others it had a nega-
tive impact on their professional identity and job satis-
faction. Not only a readiness for changing working
environments and physical sites were expressed by the
HCPs but also a readiness for facing a novel and un-
known coronavirus was dominating their narratives.
They described how they had to be ready for something
they did not know about and as such did not know how
to prepare for. To be ready for something unknown was
approached with a certain variation in motivation from
the HCPs. An important factor for the individual’s mo-
tivation and readiness to face the more or less unknown

Table 3 Key areas of frontline healthcare professionals’ experiences of balancing work life and family life during the COVID-19
pandemic
Readiness for change Frontline healthcare professionals treating and caring for patients with COVID-19 are, voluntar-
ily or involuntarily, forced to be ready to change departments as well as being ready to face
the unknown coronavirus.
A sense of being abandoned among The frontline work leads to feelings of being abandoned among their families and friends due to the
family threat of bringing the infection home and spreading the virus.
Opposing feelings about being a part of Although healthcare professionals are facing a working life filled with uncertainty and unpredictability
something bigger impacting their family life, they express opposing feelings of being a part of something bigger.
Dagyaran et al. BMC Health Services Research (2021) 21:666
working conditions was highlighted as being involved in
decisions about expected tasks and responsibilities. Fur-
thermore, perceptions of being heard and invited to re-
flect on possible consequences of agreeing to be caring
for and treating patients with COVID-19 infection was
expressed as paramount for the participating HCPs’
readiness for changes.
I received an email from my manager late at night,
where she asked if I wanted to join.
[the COVID contingency], but I did not see it [the e-
mail]. So, when I came to work the next morning,
she [the manager] was ready before I even met and
asked if she could count on me.
A threat to health for the HCPs and family
The consequences of not being able to reflect and dis-
cuss possible interventions and potential fears related to
one’s own family life filled the HCPs with mixed feelings
of, on the one hand, an obligation to be ready while it,
on the other hand, was difficult to see and think through
the possible interferences in one’s own life and family. A
prominent described threat to the HCPs’ readiness for
changes was the potential threat to their own as well as
their family’s health. The participating HCPs expressed
their experiences of a previously unknown uncertainty in
how to balance their working obligations and readiness
to be on the front in the care and treatment of patients
with COVID-19 and their family life. Suddenly they
feared for their own health but also extensive concerns
about bringing COVID-19 home to their families was il-
luminated. This fear was for some of the HCPs faced
and placed in the background of their consciousness;
while others carried the fear with them as a burden, in-
fluencing their readiness. These HCPs did, however, try
to divert the fear and do their job: “I try not to stress over
things that I can’t influence. If it comes [being infected
and bringing illness home], then I will do my best”.
The professional pride
From being an expert in one’s own field to a novice in a
new department was associated with uncertainties with
having to balance a new way of being a professional.
Despite uncertainty about caring for and treating pa-
tients with COVID-19, cohesion among the HCPs was
highlighted. They described how every HCP contributed
with their knowledge and skills leading to a sense of pro-
fessional pride and common goals and direction. A
strong metaphor of being in a war together and stepping
in when your help was needed was pervasive in the
HCPs’ narratives: ”It was like being at war … You could
say that we were the soldiers that were going to be in the
Page 5 of 10
front”. This readiness for stepping in did, however, have
consequences and required changes and flexibility at
home. Changes in working hours and variety of shifts
had a substantial impact on family life and, thereby, the
work life balance. Despite these challenges in balancing
working life and family life, experiences of this very spe-
cial team spirit providing an extraordinary effort in the
fight against COVID-19 were pointed out as being worth
it. Although it was mentally exhausting being sur-
rounded by colleagues you did not know in advance, it
was also experienced as a great strength to work with
colleagues from different specialties with a mutual goal
of making an effort of helping out in a situation associ-
ated with multiple challenges for the involved individ-
uals: “This has been the best thing I have experienced in
my career. Seeing nurses who stopped working three, five
and ten years ago come in and say: I want to help”. This
perceived community and the experience that everyone
contributed with each their professionalism and enthusi-
asm was of great importance for the individual HCPs’
readiness for change: “The best thing about being part of
this process was those people…, they ignored the obstacles
that there usually are… It was people that just made
things happen”.
A sense of being abandoned among family
The poisonous HCP
HCPs working frontline taking care of and treating pa-
tients with COVID-19 described ambiguous experiences
of being abandoned among family and friends due to the
risk of infection through their work. The very real possi-
bility of the HCPs becoming infected and catching
COVID-19 due to close contact with infected patients
raised concerns from their families who began regarding
them as potentially poisonous from whom one should
distance themselves.
He [son] didn’t want to be near me; not only because
he himself could be infected, but he was also afraid
of infecting others. He wished that his mother could
be without it [the frontline care and treatment for
COVID-19 patients].
Experiences of family members keeping extra distance
thus permeated the stories of the HCPs and such experi-
ences became ordinary daily events when meeting
others. In the HCPs’ daily life and surroundings, they felt
isolated from usual social contact with close family and
descriptions of relatives moving out of the shared home
in fear of being infected were illuminated.
My sister, her husband and my two-year-old niece
said they were isolating themselves from me. My boy-
friend lived with others and said I should not visit
Dagyaran et al. BMC Health Services Research (2021) 21:666
him there while working so closely with corona pa-
tients. There were several who withdrew from me [in
social surroundings].
A high price to pay
The consequences for the family life of HCPs working
forefront in the COVID-19 departments thus led to feel-
ings of being abandoned. Further consequences concern-
ing the children of the HCPs were also described. All of
a sudden, their children did not get invited to playdates
and some of their usual friends were not allowed to play
with children of HCPs. The social consequences for the
HCPs’ children was expressed as a very high price to pay
in order to meet their obligations of caring for and treat-
ing patients with COVID-19 and experiences of stigma
was also expressed in the stories.
The HCPs did, however, also take precautions and dis-
tanced themselves from their family where possible: “I
was not nervous for myself [as a HCP] getting infected,
but for me to infect my family. That is why we [HCP and
spouse] kept our distance from our family. We were com-
pletely isolated; we were only being with ourselves”. This
contrast between being abandoned by one’s family and
the voluntary distancing and isolation from friends and
family was expressed as an important factor in the work
life and family life balance. This balance could easily be
disturbed if feelings of being abandoned by family and
friends dominated, leading to a sense of doubt about if
the frontline work and obligations were worth it. How-
ever, the voluntary distance to their family contributed
to the HCPs’ working identity and helped maintain the
balance between work and family in a way that felt trust-
worthy for themselves.
The stigmatized HCP
Although the feeling of being distanced from the family
could either be characterized by fear and stigma from
the social environment, the HCPs understood very well
this distance. Uncertainties about the novel coronavirus
contributed to awareness among the HCPs about select-
ing when and with whom to interact socially. Likewise,
the participating HCPs experienced a great deal of con-
cern from their loved ones due to their potential risk of
getting infected with COVID-19 combined with respect
towards them due to working in the forefront in the care
and treatment of patients with COVID-19 and thereby
risking their own safety.
Opposing feelings about being a part of something
bigger
A fighting spirit
The HCPs described how they experienced a tension
marked by opposing feelings that could be difficult to
deal with. On the one hand, they talked about how they
Page 6 of 10
wanted to be part of the fight against COVID-19 and
make a difference for the sick patients in the worldwide
pandemic, while at the same time experiencing a work
life full of insecurity. Their stories illuminated how
thinking about being a part of something bigger contrib-
uted to a fighting spirit and professional pride. These
feelings did, however, for some HCPs, fade away when
actually working in the department caring for and treat-
ing the COVID-19 patients.
In contrast to the imagined expectations of being part
of a bigger contingency - namely a team of professionals
fighting an unknown virus - insecurity and ambivalent
feelings of not wanting to quit their usual jobs and let-
ting something unfamiliar and unknown impact their
family life was illuminated in the HCPs’ narratives.
It was frustrating to quit my regular job and then
suddenly have to do something completely different.
At the same time, it was an extraordinary situation
that no one had tried before. So of course, I also felt
that I had to step in and help. But I had an ambiva-
lent feeling about it. Basically, I would probably
have preferred not to be a part of it.
Putting own work on hold
An overwhelming sense of frustration due to putting
their own work on hold with an uncertain time hori-
zon without knowing when to resume was described
as particularly important for the HCPs’ adaptability of
working frontline caring and treating for patients with
COVID-19. The fact that the participating HCPs did
not know when to resume their regular job had an
impact on their motivation for doing their work and
participating in the COVID-19 contingency. The
HCPs also described how conditions such as working
hours and shifts as well as tasks constantly changed
leading to a sense of unpredictability and exhaustion.
Tasks that exceeded one’s competencies proved espe-
cially discouraging. Such challenges were difficult to
deal with and the HCPs had an urgent need for shar-
ing these with someone. When the HCPs experienced
being listened to by a colleague or their closest man-
ager, they described how they felt a relief. This relief
was expressed if the listening led to a balance be-
tween what expectations were placed on them and
the skills they had, but also when the flexibility that
the individual HCP had in relation to their family life
was recognized. So, when sharing frustrations and un-
certainties about working life, a balance with family
life could be maintained for the HCPs, however, expe-
riences of being left to oneself had a negative impact
on their family life in which the HCPs had to place
their frustrations.
Dagyaran et al. BMC Health Services Research (2021) 21:666
Being part of a professional set-up
Despite the possible overwhelming experience of being
on the front in a pandemic, the HCPs also described
how being part of a professional setup that really worked
and where everyone took an active part and were re-
sponsible, dedicated and motivated gave a feeling of be-
ing part of something bigger. The participating HCPs
related how everyone helped where they could and did
their very best and how being a part of this big picture
gave a sense of professional pride: “As a nurse, I should
not sit in my PhD office. You became a nurse, because
you want to help when there is a need, and there was a
need, and therefore I liked to join”. This relief was about
balancing the expectations they had and the skills they
had, but also the flexibility that the individual had in re-
lation to their family life. A sense of agreement among
the HCPs was illuminated in their narratives and they
described how they experienced almost never being de-
nied help from colleagues and how everybody focused
on helping each other. This helping community was par-
ticularly significant for performing in this extraordinary
situation. Furthermore, this community and feelings of
being part of something bigger led to a special vigilance
among the HCPs and their well-being which was im-
portant for balancing work life and family life. Feelings
of being part of something bigger thus outweighed the
possible negative consequences for the family life.
A shadow of fear
Although the HCPs described the importance of being
part of something bigger, they also talked about oppos-
ing feelings on the way to their first day of work when
they had to meet, care for and treat their first patient
with COVID-19. Their stories illuminated how their mo-
tivation to contribute with their knowledge and skills
could be overshadowed by fear of the uncertain and un-
known, and how the risk of getting infected themselves
or infecting their family and friends were in the fore-
ground of their consciousness in the beginning.
Before the first shift I was sitting in the car wonder-
ing if I was scared, even though I knew the isolation
regimen. We [as HCPs] end up getting infected our-
selves… So, I had such a thought on the way into
[the hospital] about what this [COVID-19] was, for
nobody knew what it was and how dangerous it
really was.
These thoughts of how dangerous the disease might
be was most prevalent in the beginning of the individual
HCPs’ meeting with infected patients, however, such
thoughts continued to lie as a shadow both in the HCPs’
working life as well as in their family life witnessing the
seriousness of the situation.
Page 7 of 10
Discussion
This study is one of only a few studies offering an in-
depth understanding of frontline HCPs’ experiences of
balancing work life and family life during the COVID-19
pandemic. A prominent disturbing factor for the partici-
pating HCPs’ family life was the fact that they, with the
outbreak of the COVID-19 pandemic, all of a sudden
had to be ready for change. They had to be ready for not
only changing departments, working hours and shifts -
but also a readiness to face an unknown virus. This
readiness for change caused feelings of an involuntary
pressure of being forced into a new and unknown work-
ing situation and responsibilities. A serious threat to
work life balance for the HCPs in the present study was
the risk of bringing infection home to the family, which
is highlighted as more frightening than the threat to
one’s own health. Such reactions during infectious dis-
ease outbreaks has been reported elsewhere [10, 24], and
these behavioral responses are designed to counteract
fear during a pandemic and may attenuate the threat to
one’s own health [25]. Balancing work life sufficiently
fosters not only satisfaction in one’s job, performance
and organizational commitment but feelings of caring
for the family is paramount [26, 27], which, however,
was challenged for the HCPs in the present study.
For some HCPs being ready for change and stepping
up to treat and care for patients with COVID-19 leads
to a sense of personal and professional growth while
others described a negative impact on their professional
identity. Evidence in occupational health literature shows
that employee control over work performance is linked
with health outcomes, and not experiencing this control
might lead to exhaustion and depressive symptoms, im-
pact on physical and mental health as well as work fam-
ily conflicts [28–30]. Norms around work time are also
about space; about being at the workplace during certain
hours which structures the lives of individuals in pro-
found ways [28]. This structure was, however, inter-
rupted for the participants in this study. Despite
descriptions of disrupted temporal structures regarding
work schedules and work hours challenging the work life
balance, a metaphor of being in war together highlighted
cohesion and team spirit among HCPs. It has been re-
ported that HCPs, despite experiencing strong pressure
of fear of infection, exhaustion by heavy workloads and
stress of caring for seriously ill COVID-19 patients still
present a strong sense of duty and identity as a HCP
[15, 31]. This dedication towards their work should,
however, not overshadow and create imbalance regard-
ing a HCPs’ family life [27, 32]. Working for a healthcare
system that is prepared and has an effective plan is mag-
nified many times over in a pandemic and should be pri-
oritized. It has further been reported how offering free
shuttle services between work and home, childcare
Dagyaran et al. BMC Health Services Research (2021) 21:666
support and meal vouchers for staff may reduce domes-
tic stress and allow for a single-minded effort for HCPs
[33].
In the present study the HCPs described a sense of be-
ing abandoned among their family and friends due to
their work on the frontline of treating and caring for pa-
tients with COVID-19. Such experiences of being aban-
doned made the HCPs feel isolated from usual social
contact. Research has described examples of how e.g.
nurses working forefront in caring for patients with
COVID-19 chose to hide the fact from their family and
friends that they were working at a COVID-19 depart-
ment in fear of how their family would react [10]. The
consequence of being abandoned points at a disturbance
in the work life balance which may cause psychological
distress for the HCPs [28]. In general high work de-
mands have been shown to be related to an increased
degree of conflict between work life and family life [34,
35], however, this study highlights a new perspective of
interest; namely a conflict based on fear. This fear cre-
ates a distance between HCPs and their families leading
to a conflict within the individual HCP if their work on
the frontline is worth it or if it is too high of a price to
pay. Research has pointed at such ethical challenges dur-
ing previous disaster outbreaks where the HCPs’ per-
sonal and possibly their family’s lives and health are at
risk, and they must weigh the option of continuing to
work or retreat to safety [36]. Such decisions that are
made daily, are based on professional and personal
values of how they perceive existing risks. It is further
described how HCPs, during uncertain times, e.g. the
current COVID-19 pandemic, are looking for trust, com-
passion, stability and hope from their leaders [37]. They
want to be part of the work solutions and are incredibly
resilient when action plans are clear which helps control
mental health issues raised by an imbalance between
work life and family life [38, 39] such as the described
deselection of the participating HCPs. In this study it
was further described how HCPs who themselves volun-
tarily chose to keep family and friends at a distance,
could more easily maintain a meaningful work life
balance.
For the participating HCPs in this study, opposing
feelings of being a part of something bigger was
expressed. On the one hand their working life on the
frontline COVID-19 contingency was shadowed with
uncertainty and unpredictability and they described how
these new and unknown working conditions impacted
on their usual family life. On the other hand, however,
these feelings of being part of something bigger contrib-
uted to a fighting spirit and professional pride which
outweighed the negative consequences; like being sol-
diers on the front. Research has reported how HCPs
might grow personally and professionally under pressure
Page 8 of 10
from being on the frontline caring and treating for
COVID-19 patients and during other pandemics [10,
40]. A work life balance is among other factors depend-
ing on a self-perceived professional job satisfaction [41].
Moreover, a congruence in work family integration indi-
cates that an individual’s own resource allocation deci-
sions toward work and family are validated by their
organization [42]. Leadership during the COVID-19
pandemic is as such paramount in supporting the front-
line HCPs in being part of a community and an environ-
ment in which helping each other is in focus in the fight
against the coronavirus. Factors that guide HCPs to re-
spond are very personal and highly connected to balan-
cing work life and family life, however, it is reported
how organizational and professional leadership can mod-
ify those factors to increase the number that are willing
to put the needs of COVID-19 patients first [36, 43].
Limitations
Through a qualitative approach, we were able to explore
the experiences of frontline HCPs in balancing work life
and family life during the COVID-19 pandemic. It is
worth noticing that the thoughts and experiences pre-
sented in this study are the most dominant among the
included HCPs, however, such dominant ideas may dif-
fer among age groups. Due to the small sample size, we
have not been able to differentiate according to an age
perspective which otherwise would have been particu-
larly interesting in the light of balancing a work life and
family life; some being young and striving for a career,
or being a family with young kids, or maybe being a se-
nior with a potential threat to own health while caring
for COVID-19 patients. Another important opt out per-
spective are the described experiences of feeling pres-
sured as a HCP caring for COVID-19 patients while
some HCPs did volunteer for the task. This issue could
be significant to address in a further study. Despite the
disadvantages of telephone interviews reducing social
cues [44], as this type of interview does not allow body
language to be used as a source of additional informa-
tion, we found that the subjects were willing to partici-
pate in the study and appreciated sharing their
experiences. Regarding the applied analysis and inter-
pretation, it is important to note that there is always
more than one way to interpret a text. The interpreted
comprehensive understanding in this article is what we
found most probable from what the participants told in
the narratives based on the researchers’ preunderstand-
ings [22]. We furthermore used a convenience sampling
strategy, as it was a rapid way to address frontline HCPs’
experiences of treating and caring for patients with
COVID-19, and thus a relatively efficient method for
gathering data in a situation where such data is highly
relevant and urgently needed. The disadvantages of this
Dagyaran et al. BMC Health Services Research (2021) 21:666
sampling method are, however, that it may include
people with resources and mental surplus [20], which
the reader should consider when transferring the find-
ings to other settings.
Conclusions
Healthcare systems worldwide are being put to the ul-
timate test and are under tremendous pressure to limit
the spread of the novel coronavirus. Most of this respon-
sibility is being shouldered by frontline HCPs. In the
present study we describe how HCPs are forced to be
ready to change departments and be those frontline indi-
viduals, voluntary as well as involuntary, treating and
caring for patients with COVID-19 infection as well as
being ready to face the unknown coronavirus. The work
life balance for these HCPs are threatened by changes in
professional responsibilities and working hours and
shifts. Furthermore, the frontline HCPs experience being
abandoned among their families and usual social circles
due to the threat of bringing the infection home and
spreading the virus. This fear challenges them ethically
and create a distance between HCPs and their families
leading to a conflict within the individual HCP if their
work on the frontline is worth it or if it is a too high
price to pay. Although an unknown and unfamiliar cor-
onavirus impacts HCPs’ family life, the participating
HCP expressed opposing feelings of being a part of
something bigger. They faced a working life filled with
uncertainty and unpredictability, but at the same time
felt being a part of something bigger that contributed to
a fighting spirit and professional pride outweighing the
negative consequences; like being soldiers on the front.
Clinical implications
In a clinical perspective these new findings can be used
to guide management during the pandemic. It seems
that these working conditions are not sustainable over a
long period of time due to the consistent psychological
and physical threat of being infected, infecting the family
and working in warm and uncomfortable equipment
causing physical symptoms. This calls for flexibility in
work schedule and periods where risk of contamination
of family is low, so that the HCPs can be with their fam-
ily in a safe manner. All management, organizational
and political tools must be used to make it attractive for
HCPs to volunteer to work frontline, e.g. sufficient and
qualified staffing in each shift, access to appropriate pro-
tective equipment, salary reflecting the importance and
risk of the task and individually planed schedules.
Abbreviations
HCP: Healthcare professionals
Page 9 of 10
Acknowledgements
The research team wishes to thank all those people who collaborated and
participated in this study by sharing their experiences. Without them, this
study would not have been possible. We also thank Phillip Helfter, RPh, for
proofreading the article and we thank Ida Ellebæk Øland for help in relation
with the transcription of the interviews.
Authors' contributions
All authors conceived and contributed to the design and conduct of the
study. ID, IEH, MH and SSR conducted the collection of data material and led
the analysis together with SKB and MM. All authors were involved in the
analysis and the writing of the manuscript. All authors contributed to the
preparation of this manuscript and read and approved the manuscript.
Funding
This work was supported by The Novo Nordisk Foundation (grant number
NNF20SA0062831), and The Heart Center, Rigshospitalet, Copenhagen
University Hospital, Denmark.
Availability of data and materials
All authors have full control of all primary raw data (interview transcripts)
and allow the journal to review our data if requested. All raw data are
written in Danish. Data are stored in a locked file cabinet in a locked room
at the Copenhagen University Hospital as requested by the Danish Data
Protection Agency. The data material used in this study are available from
the corresponding author on reasonable request which will not conflict with
the anonymity and confidentiality of the data.
Declarations
Ethics approval and consent to participate
Registration and permission was received from the authorities in the Danish
Data Protection Agency under the Capital Region of Denmark: (P-2020-276)
and the study were undertaken in accordance with the guidelines of the
Danish Research Ethics Review of Health Research Projects, Law no. 593, 14
June 2011 (http://www.nvk.dk/english/act-on-research). Given the qualitative
nature of the study, the local ethics committee in the Capital Region of
Denmark ruled that no formal ethical approval was required in this particular
case. The participants received verbal and written information about the
study prior to the study. Written informed consent was obtained from the
participants.
Consent for publication
Not applicable.
Competing interests
The authors have no conflicts of competing interest to declare.
Author details
1
Department of Infectious Diseases, the Heart Center, Rigshospitalet,
Copenhagen University Hospital, Copenhagen, Denmark. 2Heart Center,
Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
3
Institute of Nursing and Nutrition, University College Copenhagen,
Copenhagen, Denmark. 4Department of Clinical Medicine, Faculty of Health
and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
5
National Institute of Public Health, University of Southern Denmark, Odense,
Denmark. 6Department of Cardiothoracic Surgery, the Heart Center,
Rigshospitalet, Copenhagen, Denmark.
Received: 17 December 2020 Accepted: 11 June 2021
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